Angels Assisted Living

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to complete a case management visit. LPA met with administrator Simranjit during today's inspection. During today's inspection LPA reviewed resident documents and medication. At this time no deficiencies have been cited. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Sep 30, 2026

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Deficiencies

Licensing Program Manager (LPM) Troy Ordonez, Licensing Program Analysts (LPAs) Graham Gunby and Cassie Yang arrived unannounced at the facility to conduct a health and safety check inspection. LPM and LPAs met with staff and explained the purpose of the visit. During today's inspection, LPAs conducted a tour of R1's room and observed that R1's emergency exit door has a door handle restraint. R1's family member was present during the visit, and explained to LPAs that the door handle restraint was placed by Administrator as another resident (R2) would attempt to elope through R1's emergency exit. LPAs and Staff discussed that emergency exit door cannot be tampered, restricting door from opening as it is an emergency exit. A phone call was made with Administrator, LPA Yang was informed that it is a safety precaution to ensure residents does not leave. LPA Yang informed Administrator that door handle restraint will be removed by current staff during this visit. As a result of today's visit, deficiencies cited. Please see LIC 809-D. Exit interview conducted and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 24, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Sep 25, 2026

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is met as evidenced by: Based on observation, Licensee did not comply as LPAs observed R1's emergency exit door to have a restraint when prevents exit from being open, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Sep 24, 2026

Plan of correction: - Door handle restraint was immediately removed. - Licensee will take a picture of R1's emergency exit door, and submit to Licensing by September 25, 2026. - Licensee is to conduct a weekly audit of emergency doors and notify Licensing of findings by Friday of each week until October 30, 2026.

Type of visit: Case Management - Incident

On September 17, 2026, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a case management visit. LPA met with Administrator and explained the purpose of the visit. Today's visit, LPA return a resident record that was previously obtained on Monday September 14, 2026. Copies were made at the regional office and the originals were return back to the facility. As a result of today's visit, no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Sep 17, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding a deficiency observed. LPA met with staff and explained purpose of the visit. At the beginning of LPA's visit, it was observed with Administrator that R1's room has a door handle restraint, which was previously removed on September 10, 2026. LPA was informed that staff working the day prior may have placed it back on. LPA asked Administrator to remove restraint immediately. LPA informed Administrator that it was a personal rights violation. If R2 is wandering to R1's room, and R1 wishes to prevent R2 from entering R1's room, then a doorknob with a lock can be installed. With agreeance, staff can unlock door when R1 is in need for assistance. LPA emphasized the door handle restraint cannot be placed back on. As a result of today's visit, deficiencies cited. California Code of Regulation 87468.1 Personal Rights of Residents in All Facilities was previously cited on September 10, 2026. Plan of correction was received on September 11, 2026. As a repeated violation, a $250 civil penalty was issued. Please see LIC 809-D. Exit interview conducted and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Sep 15, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night... This requirement is not met as evidenced by: Based on LPA's observation, Licensee did not comply as there are door handle restraints on three resident bedroom doors, and a rod in the living used to lodge the sliding door from being opened at night, which poses an immediate risk for residents in care.the state’s words, verbatim · CDSS document, Sep 14, 2026

Plan of correction: - Door handle restraint from R1's door was removed immediately. - Licensee is to inform all individuals working and/or volunteering at the facility that residents cannot be locked within their room and/or facility. Proof of notification is required to Licensing. Screenshots are acceptable. Notification of completion is to be submitted to Licensing by September 15, 2026. Failure to correct by due date may result to $100 per day until corrected.

Type of visit: Case Management - Incident

On September 14, 2026, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit. LPA met with Administrator and explained purpose of the visit. This facility currently has five residents in care with one resident on hospice services. Administrator informed LPA the death of R1 which occurred on September 12, 2026. R1 was not on hospice services but was on home health services. During today's visit, LPA gathered R1's resident record. LPA is to make copies and will return the resident record to the facility within three business days. Additionally, LPA conducted an interview with S1 who was present during R1's passing. S2 who was present at the facility during R1's death is no longer working at the facility. LPA was informed during R1's death, only S1 and S2 was working at the facility. Upon file review, it revealed S1 and S2 does not have fingerprinting clearance association at the facility. Administrator stated a transfer for S1 has been created earlier in the morning of today's visit. Administrator needed to leave the facility and completed the LIC 308 and LIC 9182 for S1. A copy of facility roster from Guardian was provided to Administrator. This matter will remain under review by the Department until notify otherwise. Deficiencies cited, please see LIC809-D. Exit interview conducted with staff and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Sep 15, 2026

87355 Criminal Record Clearance (e) All individuals subject to a criminal record ... (b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: Based on file review, Licensee did not comply as S2 worked at the facility on September 12, 2026 without an active fingerprint clearance, which poses an immediate risk for residents in care.the state’s words, verbatim · CDSS document, Sep 14, 2026

Plan of correction: - S2 is no longer working at the facility - Licensee is to submit to Licensing of facility's hiring process to ensure that facility is in compliance to criminal record clearance that all prior to working, residing or volunteering in a licensed facility, individual is to be fingerprint cleared and associated to the facility. The following plan of correction is due on September 15, 2026. Failure to correct by due date may result to $100 per day until corrected.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(3) · Plan of correction due date: Sep 15, 2026

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review... (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87 or This requirement is not met as evidenced by: Based on file review, Licensee did not comply as S1 worked at the facility on September 12, 2026 but Administrator did not attempt clearance tranfer until September 14, 2026, which poses an immediate risk for residents in care.the state’s words, verbatim · CDSS document, Sep 14, 2026

Plan of correction: - LIC 9182 was completed by Administrator - Licensee is to submit to Licensing of facility's hiring process to ensure that facility is in compliance to criminal record clearance that all prior to working, residing or volunteering in a licensed facility, individual is to be fingerprint cleared and associated to the facility. The following plan of correction is due on September 15, 2026. Failure to correct by due date may result to $100 per day until corrected.

Type of visit: POC

On September 14, 2026, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a plan of correction visit. LPA met with Administrator and explained purpose of the visit. Today's visit, LPA and Administrator discussed the two Type A deficiencies cited on September 10, 2026, with the plan of correction due date of September 11, 2026. Plan of corrections were received via email on September 11, 2026. LPA has cleared the following deficiencies: 87465 Incidental Medical and Dental Care 87468.1 Personal Rights of Residents in All Facilities Letter of Deficiency Citations Cleared was provided. It was discussed that plan of correction for the following is due on Friday September 18, 2026. 87608 Postural Supports 87303 Maintenance and Operation No deficiencies cited on this report. Exit interview and a copy of report was provided.the state’s words, verbatim · CDSS document, Sep 14, 2026

Type of visit: Case Management - Other

On September 14, 2026, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit. LPA met with Administrator and explained purpose of the visit. Today's visit, LPA explained to Administrator the typos on the report created on September 10, 2026. LPA had amended the following report. Signatures obtained. New reports provided. No deficiencies cited on this report. Exit interview and a copy provided.the state’s words, verbatim · CDSS document, Sep 14, 2026

Allegation investigated: Staff does not ensure that facility is not free of debris.

Licensing Program Anlayst (LPA) Cassie Yang arrived at the facility to open the allegation of the complaint listed above. LPA met with Administrator and explained the purpose of the visit. During today's investigation, LPA and Administrator conducted a tour of the interior and exterior of the facility. Based on observation, LPA observed a full bed frame to be in the front yard by the front door. LPA observed the backyard to have a screen door, bed padding, boxes of trash and wheelchair on the pathway to the emergency exit. Photos were taken of the following. Based on LPA's observations, allegation, Staff does not ensure that facility is not free of debris, is substanitated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. Exit interview conducted and a copy of the report and appeal rights was provided. Substantiatedthe state’s words, verbatim · CDSS document, Sep 10, 2026 · control 59-AS-20260903162352

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 18, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, Licensee did not comply as LPA observed bed frame in the front yard; wheelchair, door screens, bed mattresses and padding, boxes in the backyard which obstruct pathway which poses an potential risk for residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: Licensee is to schedule a trash pick up for all the debris that is left at the facility. Bed frame in the front yard is to be removed; boxes of trash, broken door screens, wheelchair, mattresses and paddings are to be removed from the backyard. Proof of removal is to be submitted to Licensing by September 18, 2026. Failure to correct by due date may result to $100 per day until corrected.

Type of visit: Case Management - Deficiencies

Note: This is an amended report of the original, created on September 10, 2026. Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a complaint investigation when deficiencies were observed. LPA met with Administrator and explained the purpose of the visit. Facility has six residents in care, hospice services for one. Facility has hospice waive for five. Today's visit, LPA and Administrator conducted a tour of the interior and exterior of the facility. The following deficiencies were observed: LPA observed a hole in the wall in R1's room. LPA observed broken glass window located in the exterior sun room. LPA observed door handle restraints located at R1, R2 and R3's door. LPA was informed rods are lodged against sliding door to prevent elopements at night. LPA observed resident (R4) to have a full bed rail. LPA observed medications of Tylenol, muscle relief and Gabapentin on resident bed stand table in Bedroom R2's. Additionally, interview revealed that staff provides R2 with a full day worth of medications in the morning for R2 to self administer throughout the day. Thursday medication container was observed in R2's room. File review revealed R2 needs medication management and medication supervision. Additionally, photos were taken of the deficiencies. As a result of today's visit, deficiencies cited. Please see LIC 809-D. Note: LPA did not cite facility for being in disrepair, as California Code of Regulation 87303(a) was cited during today's visit under the complaint investigation. The hole in the wall in R1's room and broken glass window in sun room are to be corrected concurrently with plan of correction of complaint #59-AS-20260903162352, which is due September 18, 2026. Exit interview conducted and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(1)(C) · Plan of correction due date: Sep 11, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself... This requirement is not met as evidenced by: Based on LPA's observation, Licensee did not comply as LPA observed Tylenol, muscle relief and Gabapentin in R2's room along with Thursday night medications, R2's LIC 602 states R2 is unable to store own medications which poses an immediate risk for residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: - Medications were removed from R2's bedroom during LPA's visit. - Licensee is submit a statement of understanding that medications are to be centrally stored and only administered to residents as prescribed. Plan of correction is to be submitted to Licensing by September 11, 2026. Failure to correct by due date may result to $100 per day until corrected.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(6) · Plan of correction due date: Sep 11, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night... This requirement is not met as evidenced by: Based on LPA's observation, Licensee did not comply as there are door handle restraints on three resident bedroom doors, and a rod in the living used to lodge the sliding door from being opened at night, which poses an immediate risk for residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: - Door handle restraints are removed during LPA's visit. - Rod will no longer be used to restrict sliding door from being opened. -Licensee is to conduct a training to all current employees on resident rights CCR 87468.1. Notification of completion is to be submitted to Licensing by September 11, 2026. Failure to correct by due date may result to $100 per day until corrected.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Sep 18, 2026

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living...(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on LPA's observation, Licensee did not comply as LPA observed a resident who is not on hospice services having full bed rails which poses as a potential risk for residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: - Full bedrail is to be removed, half bedrail may be installed. - If R4 is a fall risk, then Licensee is to reassess R4 and create an fall risk plan to ensure the health and safety of R4 without a full bed rail. Plan of correction is to be submitted to Licensing by September 18, 2026. Failure to correct by due date may result to $100 per day until corrected.

Type of visit: Case Management - Other

Licensing Program Analyst, Bethany Mirlohi arrived on July 30, 2026 for an unannounced inspection to follow up on a substantiated complaint investigation. LPA met with Facility Representative, caregiver Edghard Zadrach and explained the purpose of today’s visit. Licensee Simran Bhatia requested to speak to LPA over the phone and have caregiver sign on reports. On October 28, 2025, the Department concluded a complaint investigation regarding the following allegations: Staff neglect resulted in a resident sustaining multiple pressure injuries and staff neglect led to the serious hospitalization of a resident, and facility did not notify responsible parties of hospitalization. On that date, the licensee was cited for three (3) citations, two (2) of those three (3) California Code of Regulations (CCR), Title 22, § 87466 Observation of the Resident and CCR, Title 22, § 87463(f) Reappraisals, are related to the allegation noted above. At the time of the complaint visit on October 28, 2025, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. Continuation on 809-C. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” Facility staff failed to ensure resident (R1) physical condition was cared for in a manner that met the resident’s needs leading to pressure injuries worsening to an unstageable degree, resulting in R1 requiring hospitalization. Today, July 30, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on October 28, 2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Edghard Zadrach name and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jul 30, 2026

Type of visit: Case Management - Other

Licensing Program Analyst, Bethany Mirlohi arrived on July 30, 2026 for an unannounced inspection to follow up on substantiated allegations resulting from a complaint investigation. LPA met with caregiver Edghard Zadrach and explained the purpose of today’s visit. Administrator Simranjit Bhatia requested to speak to LPA over the phone and have caregiver sign on reports. On October 28,2025, the Department concluded a complaint investigation regarding the following allegation: Staff neglect resulted in a resident sustaining a fracture due to a fall. On that date, the licensee was cited for three (3) citations one (1) of those three (3), California Code of Regulations (CCR), Title 22, § 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities, is related to the allegation noted above. At the time of the complaint visit on October 28, 2025, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49. Continuation on 809-C. At the time of the complaint visit on October 28, 2025, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by facility staff failure to properly monitor and/or implement a care plan for resident (R1), which resulted in R1 sustaining a fall while in care leading to hospitalization for injuries resulting from the fall. Today, July 30, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. Exit interview conducted. A copy of the report issued. Appeal rights provided. Edghard Zadrach name and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jul 30, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Graham Gunby arrived on Friday May 15, 2026 to conduct the unannounced annual inspection. LPA Gunby met with Caregiver, Harpreet Kaur, and explained the purpose of the visit. Harpreet called Administrator, Simranjit Bhatia who was unable to be at the facility and allowed Harpreet to sign the documents. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Gunby reviewed five (5) resident binders and three (3) staff files. Resident files contained the required paperwork. Staff files did not contained the required paperwork. LPA Gunby and Caregiver Harpreet, toured the facility together to ensure the health and safety of residents in care. The areas toured included bedrooms, bathrooms, kitchen, laundry room, common areas, back yard and garage. Chemicals and toxins were unlocked in the laundry room. Kitchen knives were unlocked and accessible to residents in care. Facility has a fire extinguishers in the kitchen and was last serviced on 10/29/2025. In the areas toured, there were health or safety violations observed. Deficiencies cited on LIC809-D Exit interview conducted. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, May 15, 2026

Allegation investigated: Facility has insufficient staff to meet the needs of the residents in care

*** Amended 4/9/26 *** On 2/12/26 Licensing Program Analyst (LPA) Kevin Mknelly spoke to Simranjeet BHatia by phone to deliver complaint findings for the above allegation. This complaint was a continuation, with new allegations ,to the previous investigation number 59-AS-20250207161111 The department reviewed resident records, facility records and conducted extensive interviews.The department finds that the allegations cited above are substantiated. At the time of R1’s fall on 10/24/24, S1 was the lone caregiver for 4 residents. Statements by the Administrator were that S2 was present in the home as well. A review of criminal records clearance for S1 and S2, at the time of the 10/24/24 incident found that neither S1 nor S2 were background check cleared to work at the home at that time. Therefore, sufficient and authorized staff were not present. Report continued Substantiated As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. Report reviewed with . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 59-AS-20251203132905

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87356(b)(1)(B) · Plan of correction due date: Feb 13, 2026

Criminal Record Exemption (b) In addition to the applicant, the provisions of this section shall apply to criminal convictions of the following persons: (1) (B) Any person, other than a client, residing in the facility… This requirement was not met based on records and statement. The presence of non-cleared staff resulted in no qualified staff present and was an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: Licensee will submit a procedure for submitting required documents and process of verification of all new potential employees before their presence in the facility by the POC date of 2/13/26.

Type of visit: POC

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a POC visit. LPA spoke to Administrator Simranjit Bhatia over the phone and met with care staff Edghard Zadrach. During today's visit LPA reviewed deficiencies cited on 12/16/25 and the POC's sent into CCL. LPA spoke to the administrator about reporting requirements and the forms to send into CCL. Administrator voiced understanding of the reporting requirements. POC letter was provided. Copt of report given. Exit interview conducted.the state’s words, verbatim · CDSS document, Jan 7, 2026

Allegation investigated: Staff not repositioning resident per care needs

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings into allegation listed above. LPA spoke to administrator Simranjit Bhatia during today’s visit. LPA investigated allegation, “Staff not repositioning resident per care needs”. LPA reviewed facility documents and interviewed staff and residents in care. Reporting party indicated that R1 reported that staff do not reposition them which causes them discomfort. LPA interviewed caregivers in which they stated they repositioned R1 every hour, unless R1 refused. Caregivers stated resident had behaviors of yelling out and being combative during care. LPA interviewed 2 residents in care in which they stated they heard R1 yell out from their room, especially during the night. Continuation on 9099-C. Unsubstantiated LPA reviewed R1’s LIC602 in which it states resident requires assistance with repositioning and transferring and resident has a history of skin breakdown. In addition, the LIC602 states R1 has a lack of hazard awareness and has expressions of frustration. LPA reviewed R1’s needs and service plan dated 6/5/25, in which it states R1 has behaviors of yelling out and being confused and R1 requires assistance with all ADL’s. R1 no longer lives at the facility and LPA was unable to interview R1. Due to the information gathered, LPA finds allegation to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Deficiencies were found, unrelated to allegation, due to investigation. See Case management visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 59-AS-20251021163042

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA spoke to Administrator, Simranjit Bhatia, during today’s inspection. LPA investigated a complaint investigation and during the investigation LPA found deficiencies. LPA found that R1 was a diabetic and insulin dependent. Administrator informed LPA that caregivers (non-medical professionals) were injecting R1 with prescribed insulin injections. In addition, LPA found R1 had been sent to the hospital on several occasions and administrator failed to send incident reports into CCL. Deficiencies cited on 809-D. Exit interview conducted. Copy of report provided. Appeal rights given.the state’s words, verbatim · CDSS document, Dec 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87629(b)(1) · Plan of correction due date: Dec 17, 2025

87629 Injections. (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensees who admit or retain residents who require injections shall be responsible for the following: (1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above due to caregiver providing insulin injections to resident which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 16, 2025

Plan of correction: Administrator to send into LPA a copy of their plan for diabetic residents going forward. Plan to be sent into CCL by 12/17/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Dec 29, 2025

87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above due to incidents not being reported into CCL which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 16, 2025

Plan of correction: Administrator agrees to review regulation 87211 and submit a statement of understanding into LPA by 12/29/25.

Type of visit: Office

A Noncompliance Conference (NCC) was conducted today on 12/09/2025. The meeting was held at the Sacramento North Regional Office located at 9835 Goethe Road, Suite 100 Sacramento, CA 95827. The purpose of the NCC was to discuss the Substantiated complaint of a violation. Present at today’s NCC were the Regional Manager (RM) Troy Ordonez, Licensing Program Manager (LPM) Laura Munoz, Licensing Program Analyst (LPA) Graham Gunby, LPA Lavinia Muscan, (LPA) Bethany Mirlohi, and facility licensee’s Simranjit Bhatia and Damanpreet Bhatia. Topics discussed during this meeting included: Summary of substantiated complaint findings Failure to supervise residents properly Lack of staff training and competency Failure to follow care plans and HH instructions Lack of documentation (repositioning, wound care, incident reports) Personal rights concerns Facility staffing practices Observation and monitoring of residents Restricted health conditions The facility has stated they will do the following to achieve continued and substantial compliance: Licensee will develop and implement procedures for observing and documenting changes in condition. Staff will be trained on when and how to monitor residents for changes such as wounds, decline, or safety concerns. Licensee shall plan on how to ensure staff follow all care plans, treatment orders and HH instructions. Licensee shall develop and maintain clear and complete records, including wound logs, repositioning logs, and change-in-condition notes. Licensee shall establish reliable communication processes with Home Health under Section 87609(b) as well as Hospice agencies. Licensee shall train staff on regulatory requirements for observing, identifying, and reporting changes in residents’ physical and mental condition. The licensee shall ensure documentation is completed promptly and accurately. Licensee shall submit a statement stating they will not accept residents with Stage 3 or Stage 4 pressure injuries unless an exception or Hospice approval is obtained. Licensee shall submit intake procedures for all new residents. Licensee shall submit a plan on how the licensee shall ensure reporting requirements are met and incident reports are submitted timely and accurately. Licensee shall submit a statement stating they understand injections may only be administered by an appropriate medical professional. All requested documentation shall be submitted to the Department no later than January 9, 2026. No deficiencies cited. Exit interview conducted. Report provided to Licensee.the state’s words, verbatim · CDSS document, Dec 9, 2025

Allegation investigated: Staff neglect resulted in a resident sustaining a fracture due to a fall. Staff neglect resulted in a resident sustaining multiple pressure injuries. Staff neglect led to the serious hospitalization of a resident. Facility did not notify responsible parties of hospitalization.

On 10/28/2025, Licensing Program Analysts (LPAs) Lavinia Muscan and Graham Gunby arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Caregiver Edghard Zadrach. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Substantiated Staff neglect resulted in a resident sustaining a fracture due to a fall. On October 20, 2024, R1 sustained a fall at the facility while attempting to stand from a reclining chair and reach for a walker without staff assistance. As a result of the fall, R1 suffered a displaced fracture of the right femoral neck, as confirmed by medical records. Based on R1’s physician's report (LIC602), R1 required assistance with transferring and bed mobility. Additionally, R1’s family had previously informed the facility that R1 required assistance with all transfers and needed supervision when ambulating due to a known fall risk. The department attempted to obtain R1’s assessment and needs and service plan from the facility however the licensee indicated the facility did not have requested documentation. R1 was admitted to skilled nursing for rehabilitation and returned to the facility on 11/15/2024. Based on the investigation, the facility did not implement appropriate supervision or safety interventions despite having prior knowledge of R1’s fall risk in addition to the absence of updated needs and service plan. Based on the information gathered, above allegation is SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Staff neglect resulted in a resident sustaining multiple pressure injuries. On February 5, 2025, a Home Health nurse notes report a new wound was observed on R1’s coccyx. The wound measured 5 x 4 x 0.3 cm and was documented as a suspected deep tissue injury. Medical records indicate staff were unable to report when the wound had developed. As a result, wound care orders were initiated. The investigation determined that the facility did not consistently implement pressure injury prevention and wound care measures as directed by home health nurse. This failure resulted in R1 developing a Stage 4 pressure injury to the coccyx, as well as a worsening pressure injury to the right heel. Based on the investigation, the department substantiates the finding that staff neglect resulted in R1 sustaining multiple pressure injuries. Based on the information gathered, above allegations are SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Continue on 9099-C ... PAGE 2 CONTINUED FROM 9099-C ... Staff neglect led to the serious hospitalization of a resident. Based on review of medical records, staff interviews, and facility documentation, the Department substantiated that neglect by facility staff contributed to R1’s hospitalization on February 5, 2025, due to a severe coccyx pressure ulcer and suspected dehydration leading to acute kidney injury. The facility failed to assess their capacity and capability to care for R1, even with home health support. The facility failed to coordinate with home health care for R1's needs to address R1's pressure injury, and transfer R1 to a higher level of care. Based on the information gathered, above allegations are SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Facility did not notify responsible parties of hospitalization. Based on records reviewed, the records revealed on February 5, 2025, R1 was transported to the hospital via 911 due to a severe coccyx pressure injury. The investigation determined that the facility did not notify the responsible party, or any family members, of the hospitalization. Family members were informed by the hospital that R1 was admitted to the hospital. Based on the information gathered, above allegations are SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted, deficiencies cited on LIC809D per Title 22, and appeal rights were given. A civil penalty in the amount of $500 is assessed. The licensee was informed during today’s visit that a civil penalty is under review and may be assessed at a future date according to Health and Safety Code §1569.49.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 59-AS-20250207161111

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Oct 29, 2025

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not evidenced by: Based on record review and interviews, the licensee did not comply with this section as R1 was not regularly observed for changes. This poses an immediate Health and Safety risk to resident in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Licensee shall send a letter of understanding of this regulation and shall conduct staff training. All POC documents are due by 10/29/2025. $500 Civil Penalty

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(f) · Plan of correction due date: Oct 29, 2025

Reappraisals (f)The licensee shall immediately, or as soon as reasonably possible, communicate with the resident and, if applicable, the resident's representative, about any significant change in condition and the recommendation, if any, of the appropriate licensed medical professional, and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident’s record. This requirement is not evidenced by: Based on interviews and record review, the licensee failed to notify R1’s responsible party when R1 was admitted to the hospital. This poses an immediate Health and Safety risk to resident in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Licensee shall send a letter of understanding of this regulation and shall conduct staff training. All POC documents are due by 10/29/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 29, 2025

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not evidenced by: Based on interviews and record review, the licensee failed to provide care and supervision which resulted in R1’s fall leading to a fracture. This poses an immediate Health and Safety risk to resident in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Licensee shall send a letter of understanding of this regulation and shall conduct staff training. All POC documents are due by 10/29/2025.

Allegation investigated: Licensee does not ensure staff dispensing medication to residents are appropriately trained. Licensee does not ensure facility has adequate supplies to provide care to residents.

On July 23, 2025, Licensing Program Manager (LPM) Laura Munoz, Licensing Program Manager (LPM) Troy Ordonez, and Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to investigate complaint regarding the allegations listed above and met with Administrator Simranjit Bhatia. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unsubstantiated Licensee does not ensure staff dispensing medication to residents are appropriately trained. Based on interviews with staff, staff indicated they received medication training. Although the licensee could not show proof that the medication training was given, two (2) staff interviews stated that they did receive medication training upon hire and on a regular basis. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Licensee does not ensure facility has adequate supplies to provide care to residents. Based on department observation and interviews, it was determined that the facility has adequate supplies to provide care to residents. Two (2) staff interviews indicated that although some resident supplies are not included in the admission agreement, the facility does cover supplies to provide adequate care to residents. Four (4) resident interviews indicated that their needs were being met. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. Report left with Administrator.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 59-AS-20250717160132

Allegation investigated: Unlawful eviction. Do to neglect, resident sustained a pressure injury.

On 05/28/25, Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met Administrator Simranjit Bhatia and explained the purpose of today's visit. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unsubstantiated **Report continued from 9099...... Allegation- Unlawful Eviction- UNSUBSTANTIATED LPA investigated allegation "unlawful eviction" and interviewed administrator. Administrator stated resident, R1 got admitted to facility on 01/06/23 and was transferred out to hospital on 04/12/24 due to change in condition. Administrator stated that R1 was very challenging with their care needs. Administrator stated they verbally informed R1s responsible party and placement agency that new placement was needed but a written 30-day notice was not given to R1. In April 2024, R1 was sent out to the emergency department. R1 needed to be discharged and administrator contacted R1 to discuss house rules via phone if R1 willing to return but R1 declined to follow any house rules and refused to return to facility. it was learnt that R1 was willingly moved to another facility after hospital discharge. Based on gathered information, this allegation was found to be UNSUBSTANTIATED. Allegation -Do to neglect, resident sustained a pressure injury. UNSUBSTANTIATED Department conducted record review and interviews with staff and witnesses to investigate this allegation. Record review reflected that resident, R1 got admitted to facility on 01/06/23 and was transferred out to hospital on 04/12/24 due to change in condition. It was also noted that R1 was on hospice care from 01/16/23 till 02/14/24 and on home health care from 02/16/24 till their hospital visit on 04/12/24. Record review reflected that R1 has wound care treatment during their facility stay and all parties were aware about those health issues. Administrator and 2 witnesses interviews reflected that R1 was not complaint with their wound care plan, but it was not due to staff’s neglect or supervision. Based on gathered information, this allegation was found to be UNSUBSTANTIATED. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, May 28, 2025 · control 59-AS-20250318082622

Type of visit: Case Management - Other

On 05/28/25, Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced. LPAs met with Administrator Simranjit Bhatia and explained the purpose of the visit. LPA conducted a case management visit while doing complaint follow up visit today, complaint control#: 59-AS-20250318082622. During the complaint investigation, it was learnt that resident, R1 file was missing or having incomplete documents which were required per Title 22 Regulations as below; : missing pre-appraisal admission document : admission agreement was found to be incomplete : ID form was found to be incomplete As a result of today’s visit , LIC9102 -Technical Assistance was issued. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, May 28, 2025

Type of visit: Required - 1 Year

On 5/12/2025 LPA Tryon visited the facility unannounced to conduct an annual visit. LPA met with staff. Licensee was not available at the time of the visit, but arrived about 30 minutes later. LPA toured the facility including common areas, kitchen, outside areas, bedrooms, bathrooms, storage.. Smoke detectors, carbon monoxide detector installed and functioning. Fire Extinguisher present and charged. Medications are centrally stored and locked. Medications are stored in original pharmacy containers. Centrally stored medication logs are maintained for each resident. Food supplies are adequate to meet the requirement of 2 days perishable food and 7 days non-perishable food. Bedrooms are appropriately furnished with required furniture. Bathrooms are clean and functional. There is outdoor space available in the back yard. Cleaners and other potentially hazardous items are inaccessible to residents. LPA reviewed 2 resident files and 2 staff files. Files include required information. LPA reviewed the CARE Tool with staff. LPA made several suggestions that may help things run more smoothly and we discussed several issues. At this time, facility appears to be in substantial compliance. No deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, May 12, 2025

Type of visit: Case Management - Incident

On 04/16/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced. LPA met with Administrator Simranjit Bhatia and explained the purpose of the visit. LPA conducted a case management visit while doing complaint follow up visit today, complaint control#: 59-AS-20250318082622. During the complaint investigation, it was found that S1 was not criminally record cleared or associated to this facility and was working at the facility for more than 5 days at day of visit. The Administrator admitted that the facility failed to request a criminal clearance association for S1. S1 was sent home immediately and administrator understand that no staff can work until they are fingerprint cleared and associated with facility. As a result of todays visit deficiency cited and immediate civil penalty was assessed. Exit interview conducted and a copy of the report, LIC809G and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Apr 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Apr 17, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) .. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above due to caregiver, S1 was not being fingerprint cleared and associated with the facility which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 16, 2025

Plan of correction: Licensee will submit a statement of understanding to LPA that all staff must be fingerprint cleared and/or transferred prior to working in the facility. POC due 04/17/25. Immediate civil penalty of $500.00 was assessed today.

Allegation investigated: Staff does not ensure facility has adequate food supply

Amended: On October 2, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint #59-AS-20240821160241. LPA met with Michelle , and informed her the reason for the visit. The Department received a complaint alleging staff does not ensure facility has adequate food supply, Staff are not properly trained, and staff does not properly document resident's medications. LPA investigated the allegations by reviewing food receipt, trainings forms and MARs (Medication Administration Records) log. Regarding the allegation that staff does not ensure facility has adequate food supply, LPA interviewed 2 staff and 5 resident. All residents stated there’s always food in the house. According to 5 residents, the licensee will get all residents grocery list on a weekly basis and purchase everything on the lists. Kitchen area was toured along with food storage units. LPA observed at this time and during prior visits made out to this facility, that food for 2-day perishable and 7-day nonperishable quantities were sufficient to meet To continue see 9099-C... Unfounded 9099-C... Based on LPA's observations and interviews which were conducted and record interviews, the preponderance of evidence standards has been met, therefore, the allegation is found to be SUBSTANTIATED, meaning, the preponderance of evidence standards has been met. The deficiency will be cited. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit. Exit interview held, Appeal Rights discussed, copy of report given. 9099-C... the needs of the residents. The complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. Per California Code of Regulations, Title 22, no citations were issued. An exit interview was conducted and a copy was given to Michelle.the state’s words, verbatim · CDSS document, Oct 2, 2024 · control 59-AS-20240821160241

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(3) · Plan of correction due date: Oct 2, 2024

87465(c)(3) (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This is evident by the facility not having a medical administration record for any of the residents.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: The Licensee shall have residents medical file at facility at all times and document all medications given to each resident. Licensee shall document why it is important to document all medications given. This shall be completed by 10/15/2024 and submitted to LPA.

Allegation investigated: Licensee does not ensure that staff have a criminal clearance

Amended to make Public: On October 2, 2024, Licensing Program Analyst (LPA) De Anna Williams-Lyons arrived unannounced to deliver findings for complaint # 59-AS-20240906113641. LPA met with Michelle Fraunhoffer, Caregiver, and informed her the reason for the visit. The Department received a complaint alleging the Licensee does not ensure that staff have a criminal clearance, Licensee does not ensure that staff have a medical clearance, and Licensee did not report an incident to the appropriate parties. LPA investigated the complaint by reviewing resident and facility files and conducting interviews with residents and staff. LPA also obtained staff schedules and rosters and other documentation pertinent to the complaint. LPA reviewed the facility’s active employee roster. On the active roster, there was 15 potential staff that could be hired. The facility has employed 7 out of the 15 on the list. The 7 employees hired had criminal background clearances from the department in their employee file. Licensee stated only those that pass the Criminal Background Clearance will be considered for employment. Allegation Unfounded. Unfoundedthe state’s words, verbatim · CDSS document, Oct 2, 2024 · control 59-AS-20240906113641

From the deficiency page — Deficiency type: Type A · Section cited: CCR 47411(f) · Plan of correction due date: Oct 2, 2024

47411(f) Personnel Requirements All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. Based on interviews conducted and records reviewed, this requirement was not met as evident based on facility didn't ensure staff had a Health Screening prior to working at facility, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Licensee shall ensure staff employeed has a Health Screening Prior to working at the facility. Licensee shall document why it is important to ensure this requirement and submit to LPA no later than 10/15/2024.

Type of visit: Post Licensing

On September 17, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a Post Licensing Inspection. LPA met with Sim Bhatia, Licensee, and informed her the reason for the visit. This Post Inspection is because the facility has 2 complaints at this time and wanted to check in on the residents and staff. The facility has been licensed for 1 year. Their total capacity 6. LPA will concentrate on the facility's medication and documentation in the files. LPA reviewed the facilities resident's files and staff files. LPA also reviewed the Medical Administration Records for the residents. Fire extinguisher was CURRENT and ready for emergency use. Smoke Alarms and carbon monoxide detectors were in good condition. First Aid was complete with scissors tweezers and thermometer and guide. Licensee has 2 employees and 2 on calls that have fingerprint cleared and a current First Aid Certificate. The Fire Clearance is for 6 NON-AMBULATORY, OF WHICH 1 MAY BE BEDRIDDEN. APPROVED HOSPICE WAIVER FOR 5. The facility serves RCFE/DEMENTIA. LPA reviewed all resident files which included Service Plans, Admission Agreements, Emergency Contact,, physician reports, and Service and assessments. Staff files included first aid certificates, Criminal Clearances, health screens and emergency contacts list. Per California code of Regulations, Title 22, no citations were issued. An exit interview was conducted and a copy of this report was given to Sim.the state’s words, verbatim · CDSS document, Sep 17, 2024

Type of visit: Required - 1 Year

On April 24, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a Required Annual Inspection. LPA met with caregiver Camille and informed her the reason for the visit. LPA and Camille completed the infectious control plan questionnaire with no issues. LPA toured the facility inside and out. The inside of the facility was observed to be in good condition The temperature was 70 degrees F. LPA observed a table in the dining area. Plates and utensils were observed to be in place. Knives are observed to not be locked in the kitchen. Dishwasher, stove, refrigerator, and microwave all present and working. This facility has a fire clearance. The facility also has a fully charged fire extinguisher and functioning smoke alarms/carbon monoxide detector and all exit doors have sound alarms. Food storage was adequate in the facility. Hot water temperature was measured at 105 F which meets the 105 F - 120F regulations. Storage and lighting were adequate in the home. All 6 bedrooms were observed to have furniture as required by Title 22 Regulations. Bathrooms were observed to be in good repair. There's adequate linens such as sheets, blankets, etc. were observed. Cleaning supplies and toxins were found to be locked. Medications are located in the hallway closet locked . To continue see 809 -C.... LPA reviewed the exterior of the facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards. The facility Medication Administration Record was complete and current. LPA reviewed 3 resident files and 2 staff files. Resident's Records reviewed indicated emergency contacts, Assessments, Admission Agreements and Physician's Reports were all current and up to date. Staff records reviewed revealed current First Aid & CPR certificates, Health Screenings and Emergency Contacts were all up to date and the facility is conducting staff training as required. Per California Code of Regulations Title 22, no deficiencies were found. The administrator shall submit updated copies of the(LIC 500) Personnel Report, (LIC 308) Designation of Administrative Responsibility,(LIC 610D) the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file. Administrator shall submit the listed documents to Licensingno later than May 24, 2024. An exit interview was conducted and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 24, 2024